- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Altered O2 supply
- Alveolar-capillary membrane changes
- Altered blood flow
- Altered oxygen-carrying capacity of blood
As evidenced by: [Check those that apply]
- Confusion
- Somnolence
- Restlessness
- Irritability
- Cyanosis
- Inability to move secretions
- Hypercapnia
- Hypoxia
- Dsypnea
- Nasal Flaring
Patient’s Diagnosis: –
Date:-
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- maintains optimal gas exchange as evidenced by: normal ABGs, alert responsive mentation, and no further reduction in mental status.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess respirations: note quality, rate, pattern, depth, and breathing effort. | Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. |
| Assess for signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal shift to affected side. | Collapse of alveoli increases physiological shunting. |
| Monitor vital signs. | With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise. |
| Assess for changes in orientation and behavior. | Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes, such as memory changes. |
| Monitor arterial blood gases (ABGs) and note changes. | Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. |
| Use pulse oximetry to monitor O2 saturation and pulse rate continuously. | Pulse oximetry is a useful tool to detect changes in oxygenation. O2 saturation should be maintained at 90% or greater. |
| Assess skin color for development of cyanosis. | For cyanosis to be present, 5 gm of hemoglobin must desaturate. |
| Monitor chest x-ray reports. | Chest x-rays may guide the etiologic factors of the impaired gas exchange. |
| Assess patient's ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. | Retained secretions impair gas exchange. |
| Maintain oxygen administration device as ordered, attempting to maintain O2 saturation at 90% or greater. | To provide for adequate oxygenation. |
| Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees). | This promotes lung expansion and improves air exchange. |
| Change patient's position every 2 hours. | This facilitates secretion movement and drainage. |
| Suction as needed. | To clear secretions if the patient is unable to effectively clear the airway. |
| Encourage deep breathing, using incentive spirometer as indicated. | To reduce alveolar collapse. |
| Encourage or assist with ambulation as indicated. | To promote lung expansion, facilitate secretion clearance, and stimulate deep breathing. |
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